Maternity Test 2 Chapter 22 Application

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule? 2 cm/hour for cervical dilation 1/2 cm/hour for cervical dilation 1 cm/hour for cervical dilation 1/4 cm/hour for cervical dilation

1 cm/hour for cervical dilation

A biophysical profile has been completed on a pregnant woman. The nurse interprets which score as normal? 3 7 5 9

9

A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priorityfetal assessment the health care provider should focus on at this time? Monitor heart rate for tachycardia. Monitor fetal movements to ensure they are neurologically intact. Look for late decelerations on monitor, which is associated with fetal anoxia. Monitor fetal blood pressure for signs of shock (low BP, high FHR).

Look for late decelerations on monitor, which is associated with fetal anoxia.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth? Lamaze position McRoberts maneuver fundal pressure positioning the woman prone

McRoberts maneuver

The nurse is caring for a woman at 32 weeks' gestation who expresses deep concern because her previous pregnancy ended in a stillbirth. The nurse would encourage the mother to have what screening test? Nonstress test (NST) Contraction stress test Doppler ultrasound Vaginal ultrasound

Nonstress test (NST)

The nurse is assisting with a vaginal birth. The patient is fully dilated, 100% effaced and is pushing. The nurse observes the "turtle sign" with each push and there is no progress. What does the nurse suspect may be occurring with this fetus? Nuchal cord Shoulder dystocia Umbilical cord prolapse Breech position

Shoulder dystocia

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? The client is having a moderate amount of rubra lochia. The client is afebrile. Bowel sounds are active. The client requires assistance to ambulate in the hallway. The fundus is located 2 fingerbreadths above the umbilicus.

The fundus is located 2 fingerbreadths above the umbilicus.

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? Use McRoberts maneuver. Use Zavanelli maneuver. Apply pressure to the fundus. Attempt to push in one of the fetus's shoulders.

Use McRoberts maneuver.

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth? monitor for a cardiac anomaly extensive lacerations brachial plexus assessment assess for cleft palate

brachial plexus assessment

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? noting the space at the maternal umbilicus auscultating the fetal heart rate at the level of the umbilicus applying suprapubic pressure against the fetal back continuing to monitor maternal and fetal status

continuing to monitor maternal and fetal status

It is necessary for the mother to have a forceps delivery. To reduce complications from this procedure, the nurse should: empty the mother's bladder. have anesthesia provider present. call the neonatologist. provide pain medication.

empty the mother's bladder.

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? brief. well coordinated. poor in quality. erratic.

erratic

A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? trial labor external cephalic version vacuum extraction forceps birth

external cephalic version

A nursing instructor is teaching students about fetal presentations during birth. The mostcommon cause for increased incidence of shoulder dystocia is: increased number of overall pregnancies. poor quality of prenatal care. longer length of labor. increasing birth weight.

increasing birth weight.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? hemorrhage infection pulmonary emboli depression

infection

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? knee-chest sitting side-lying supine

knee-chest

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to: attach a fetal monitor to determine fetal status. ask her to push with the next contraction so birth is rapid. place a hand gently on the fetal head to guide birth. assess blood pressure and pulse to detect placental bleeding.

place a hand gently on the fetal head to guide birth.

The nursing student doing a rotation in obstetrics is talking to her preceptor about dystocia. She asks what is meant by the term "expulsive forces," better known as the "powers." The preceptor correctly tells her that the "powers" include which factors? Select all that apply. analgesia mother's age presentation fetal development position

presentation fetal development position

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? "I know you are hurting, but you can have another baby in the future." "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" "I will make handprints and footprints of the baby for you to keep." "Have you named your baby yet? I would like to know your baby's name."

"I know you are hurting, but you can have another baby in the future."

A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question? "Maybe your baby has developed hydrocephaly and the head is too swollen." "Maybe your uterus is just tired and needs a rest." "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby."

"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

A multipara woman is fully dilated and effaced and has been pushing for over 2 hours. The student nurse observing asks the nurse, "What is causing this to last so long?" Which response by the nurse would be the most accurate? "The fetal head and shoulders are too large to get through the canal." "The woman's bladder is too full, so the fetus cannot descend." "The fetus probably turned to a breech position at the last minute." "The fetal head is in an abnormal position."

"The fetal head is in an abnormal position."

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action? Removing the infant quickly. Keeping the communication lines open. Leaving the parents alone. Contacting a grief counselor.

Keeping the communication lines open.

A mother in labor with ruptured membranes comes to the labor and delivery unit. It is determined that the fetus is in a single footling breech presentation. The nurse assesses the mother for which complication associated with this fetal position? Brachial plexus injury Uterine atony Cord prolapse Placental abruption

Cord prolapse

The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist with the birth? Reduce risk of complications The fetus is descending too slowly Abnormal position of the fetal head To lessen the mother's pain

Abnormal position of the fetal head

While the placenta is being delivered after labor, a patient experiences an amniotic fluid embolism. What should the nurse do first to help this patient? Administer oxygen by mask. Increase intravenous fluid infusion rate. Put firm pressure on the fundus of the uterus. Tell the patient to take short, shallow breaths.

Administer oxygen by mask.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth? Delay breastfeeding the newborn for a day. Ensure that the client does not cough or breathe deeply. Assess uterine tone to determine fundal firmness. Avoid early ambulation to prevent respiratory problems.

Assess uterine tone to determine fundal firmness.

The nurse is caring for a mother laboring with her second baby. Her last vaginal exam revealed 5 cm dilated at a -2 station. The nurse notes on the monitor that the fetus is now experiencing severe bradycardia and variable decelerations. What should the nurse do first? Call for help Apply oxygen to the mother Lift the head off the cord Notify the obstetric provider

Call for help

The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment? Need to have the baby manually rotated Shorter dilation (dilatation) stage of labor Experience of additional back pain Necessity for vacuum extraction for birth

Experience of additional back pain

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? Administer oxytocin intravenously at 4 mU/minute. Prepare the client for a cesarean birth. Place the client in lithotomy position for birth. Perform artificial rupture of membranes.

Prepare the client for a cesarean birth.

The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? Administer an analgesic to the client. Prepare for a precipitous vaginal birth. Prepare to assist the care provider with an amniotomy. Prepare the client for a cesarean birth.

Prepare the client for a cesarean birth.

When preparing a mother for a trial of labor after cesarean (TOLAC), what information should the nurse include in the teaching plan? There may be a shorter active phase of first stage of labor. There may be a shorter latent phase of labor. There may be a longer active phase of first stage of labor. There may be a longer latent phase of labor.

There may be a longer active phase of first stage of labor.

The nurse is evaluating the fetal heart rate rhythm strip and determines that the amplitude varies with a rate 15 to 20 beats/min. What does this assessment finding indicate to the nurse about variability? Variability is normal. Variability is absent. Variability is minimal. Variability is marked.

Variability is normal.

A patient is confirmed to be in labor. Upon examination she is 3 cm dilated and the fetus has started to descend. Three hours after admission, however, she appears not to be progressing. She remains only 3 cm dilated, and the fetus is in the same position. The physician correctly terms this as which of the following? disorder of protraction precipitous delivery disorder of arrest precipitous labor

disorder of arrest

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client? hypotonic contractions uncoordinated contractions hypertonic contractions Braxton Hicks contractions

hypotonic contractions

A nursing student correctly identifies the causes of labor dysfunction to include which factors? Select all that apply. problems with the mother's diet problems with the uterus problems with access to health care problems with finances problems with the fetus

problems with the uterus problems with the fetus